The unfinished agenda and inequality gaps in antenatal care coverage in Ethiopia

Antenatal care is a widely used strategy to deliver recommended health interventions during pregnancy in order to reduce maternal and newborn morbidity and mortality and improve newborn survival [1‐3]. Ethiopia adopted focused antenatal care (FANC) model which was recommended by the World Health Organization’s (WHO) since 2002 [4, 5]. The focused antenatal care model recommends women to make at least four antenatal care (ANC) visits during their pregnancy [4, 6, 7].

The health care that a mother receives during pregnancy is important for the survival and well-being of both the mother and her baby [8]. Globally, more than 800 women are estimated to die daily from complications related to pregnancy and childbirth, countries in Sub-Saharan Africa account for the majority of deaths [9, 10]. The high maternal mortality ratios strongly correlate with low antenatal coverage [11]. ANC also provides opportunities to provide the necessary care to reduce low birth weight and improve newborns’ survival [3, 12].

In Ethiopia, the ANC coverage has been steadily increasing in the last two decades [10, 13]. However, both the initiation of ANC and completion of the recommended four contacts have been significantly lower than the target set for the nation [14]. The ANC utilization has been also significantly lower in some population group than others raising serious concerns of inequalities [15]. Equitable access to quality maternal health care is essential to improve maternal health outcomes and are widely advocated for [16]. In low-income countries, inequality by residential location (urban/rural), household wealth [17, 18], and maternal educational status [18, 19] are recognized as major impediments to achieving high coverage.

The failure to achieve national targets appears to have been deceived by the remarkable coverage improvements from one round of DHS to the next [10, 20]. Examining the trend with an eye on the target and identifying inequality gaps are necessary to inform decision making and to push harder to reach targets if and when necessary.

This study examined the trends in ANC/ANC 4+ national coverage and the inequality gaps in Ethiopia using a large representative sample from the Demographic and Health Surveys (DHS). The findings of this study provide empirical evidence for policy decisions to ensure equal access and utilization of ANC services in Ethiopia.

The findings indicated that the national ANC and ANC4+ trend has been steadily increasing since 2000; however, the projected antenatal coverages are unlikely to meet the national targets for 2025, more notably for ANC 4+. The national target set for 2025 by the HSTP II is 81% [27]. The country has achieved significant reductions in the inequality gaps by household wealth, maternal education and place of residency. However, there still remain obvious gaps between the advantaged and disadvantaged groups in all three parameters observed in this study. Lower household economic status and maternal education are key drivers for urban-rural inequalities.

The increasing trend in initiation of ANC and completing the recommended four ANC can be explained by the expansion of new health facilities, the active engagement of community health workers (known as health extension workers in Ethiopia), and increased investment on maternal health services including fee exemption for such services in public health facilities in Ethiopia [28]. However, the target set for the past and current periods were not met which could be either due to ambitious targets setting or implementation challenges including supply side factors such as lack of medicines, unskilled health care professionals, poor attitude and unprofessional conduct of health workers [28, 29], and previous unpleasant experience at the health facilities hamper demand for services [11].

There are also many demand side factors that hinder initiation and completion of antenatal care. Its utilization is heavily hindered by far distance between residence and health facilities, lower educational status of both mothers and husbands, and poor economic status, [20]. Lack of transportation make repeated contacts to the health facilities very difficult for mothers, thus, demand is likely to decrease especially if the pregnancy is considered to be smooth by the mothers’ own assessment [14]. As the pregnancy advances mothers living far from health facilities may find it very difficult to walk long distances and fail to finish all the recommended ANC visits [30]. Financial and logistical problems are also substantial impediments to utilization of the ANC services in low-income settings [11]. ANC demand and utilization are also affected by factors such as age of the mother, previous history of ANC visit, parity, number of under-five children, and experiences during previous pregnancies and child birth [2, 14, 19, 31].

The significant reduction in the inequality gaps by household wealth was mainly as a result of higher percentage gain in the lower quintiles, which can be attributed the government’s pro-poor health policy and efforts to strengthen the grassroots level primary health care services [32]. However, the coverage in the lowest wealth quantile is still unacceptably low as also indicated by previous reports [32, 34]. This indicates the indirect costs to attend ANC are still prohibitive among the poor even the actual care is provided free of charge [35, 36]. Other important contributors to the disparity included lack of time to travel to a health facility; many poor mother may not have support at home for child care and other household chores [33, 37].

The inequality gap by place of residence is also closing for ANC coverage mainly due to a bigger improvement in rural areas compared to urban areas. Previously, health care facilities were more clustered in urban areas, in the last two decades health facilities have been built closer to rural residence [38], which is also related to increasing urbanization and establishment of small towns that can also provide accommodation for health workers [39]. Building health facilities closer to the rural population offers a better chance to utilize services even for mothers from the lower socioeconomic status [33, 40]. Urbanization also promote services utilization, women in urban areas use antenatal care service more frequently than those reside in rural areas due to ease of access [41]. In Ethiopia, the health infrastructure, distributing professional health care providers and human resource development at the primary health delivery points have shown significant improvement in rural areas in the last two decades, which was critical to closing the inequality by place of residence [42].

The inequality gaps by maternal education also revealed a significant reduction. Although coverage is still low in the lower educational groups it has shown remarkable improvement in the last two decades. This shows supporting women with lowest education to attend ANC can substantially reduce the gaps [17]. Educated women have a better socioeconomic status that offer them financial autonomy to seek medical care, in addition to a better access to information that allow them to make informed and positive decisions to seek care [14, 20].

The findings of this study have huge implication for practice and policy. Although efforts so far have bear fruits in terms increasing coverage, they were not matching the country’s ambition to make service accessible to the large majority of the population. Thus, it is important to consider policy options to reach more vulnerable and remotely located women. A one-size fit all approach need to be reconsidered to address the diversity of the population in terms of lifestyle (agrarian versus pastoralist) and residence (rural versus urban). The strength of this paper is usinWg the DHS data which has a large representative sample size collected on several points over a period of two decades. However, the EDHS data relied only on the ability of respondents to correctly recall and report past events without any means of further verification by the interviewers, we considered this recall bias as one of limitations of the study... Another strength of this study is the consideration given to past performance levels to make projections in to the future plan period.

Despite a steady progress in antenatal coverage over the last 20 years the national coverage remained below the national target at all survey points. Even if there is significant improvement in the overall utilization of antenatal care in the country; the poor, uneducated and rural women remained constantly disadvantaged. We recommend expanding access to maternal health services at grassroot levels to further reduce the inequality gaps and increase coverage. Specific interventions that help overcome economic and educational disadvantages are critical. Such interventions may also require strong multisectoral efforts.